INTE-AFRICA researchers recently published a commentary in BMJ Global Health entitled “Ethical issues in intervention studies on the prevention and management of diabetes and hypertension in sub-Saharan Africa.

Lead authors Shayo, Van Hout and Birungi et al. highlight the sharp rise in chronic diseases, such as diabetes and hypertension, in sub-Saharan Africa (SSA) and underline the continued prevalence of HIV in the SSA context. Prevalence estimates of diabetes and hypertension in SSA stand at about 5% and 25%, respectively, and HIV at 5% or much higher, depending on the setting.

Such a surge in chronic diseases, which require lifelong treatment, has resulted in an increased need for improving and expanding chronic care services. This presents a challenge for the region, where the health systems have historically focused on tackling acute infectious diseases.

While HIV services and antiretroviral therapy are regularly accessible in SSA, with an estimated >65% of people to be living with HIV in regular care, this scenario is a starkly different reality for diabetes and hypertension care. As little as 5-20% of those living with diabetes or hypertension are estimated to be in regular care. This gap in care can potentially be attributed to the lack of constant supply of diabetes and hypertension medicines, and when they are available, they are not usually provided free of charge except for those with exemptions.  In contrast, this is a challenge not faced by most people living with HIV, as antiretroviral therapy is widely available and free of charge.

In this commentary, the authors discuss the implications of a limited supply of medicines and potential solutions to track equity in this dimension. In particular, they consider what the ethical approach for a research programme in terms of medicine provision and sustainability should be when alternative affordable and accessible supplies are unavailable.

Key questions addressed by the authors include:

  • Should research be conducted in real-world conditions where medicines supply for hypertension and diabetes is patchy?
  • Should the research programme purchase the medicines for participants to enable the research run smoothly?
  • Is there an obligation to provide medicines to non-trial participants?
  • Should the health facilities be encouraged to procure a greater supply of medicines to facilitate the research and enhance sustainability?

The authors conclude that it is clear that the research would likely produce meaningless results/outcomes if the supply of medicines was erratic. At the same time, the research programme typically cannot just purchase the necessary drugs for its trial participants. A solution authors suggest for this conundrum is through discussion and working in partnership with key stakeholders: the policy-makers, disease control managers, healthcare providers, patient groups, and community representatives.



Shayo E, Van Hout MC, Birungi J, et al. Ethical issues in intervention studies on the prevention and management of diabetes and hypertension in sub-Saharan Africa. BMJ Global Health 2020;5:e002193. doi:10.1136/ bmjgh-2019-002193